The management of diabetes and kidney disease has changed dramatically in recent years. Until the mid-2000s, renin-angiotensin system (RAS) inhibition, glycemic control, blood pressure control, and lifestyle management were the only options. Dipeptidyl peptidase 4 (DPP4) inhibitors, glucagon-like peptide-1 (GLP-1) receptor agonists, and sodium-glucose co-transporter 2 (SGLT2) inhibitors are game changers. But only if patients can access them.
Maryam Afkarian, MD, PhD
“We have no shortage of new tools to manage diabetes and kidney disease,” said Maryam Afkarian, MD, PhD, the Depner Endowed Professor in Nephrology at the University of California, Davis. “Sadly, we are also faced with barriers and challenges to the practical application of these tools.”
Dr. Afkarian will explore some of those barriers in patients with early kidney disease during the symposiumTranslating Diabetes and Kidney Disease Clinical Trial Findings into Clinical Practice,which will begin at 9:00 a.m. ET Tuesday, June 29. Meg J. Jardine, MD, PhD, Director of the Clinical Trial Center (CTC) and Director of the CTC’s Kidney Health Research at the University of Sydney, Australia, will discuss the care of patients with advanced kidney disease.
Lack of time, lack of coordination between specialists, and lack of early access to specialist care are long-standing challenges for diabetic kidney disease (DKD) treatment, Dr. Afkarian said. So is the continuing growth in diabetes numbers.
In 2018, 13% of the U.S. adults had diabetes—a number that is rising as the general population becomes more obese and sedentary, she said. Diabetes prevalence has increased alongside COVID-19, too. Dr. Afkarian’s patients have gained an average of 10 to 40 pounds during the pandemic, she said.
“That acute jump in obesity and faster march toward diabetes is one more massive burden on a health care system that was barely functioning before the pandemic began,” Dr. Afkarian said.
As the number of people diagnosed with diabetes has continued to rise and diabetes treatment options have expanded, the management of uncomplicated diabetes care has begun to shift from internal medicine to endocrinology, Dr. Afkarian continued. Internal medicine can’t keep up with the flood of new management tools in diabetes, so they have to engage endocrinology much earlier, she added.
“I suspect endocrinology itself is a stressed specialty,” Dr. Afkarian said. “Diabetes is just one of the conditions they deal with. The endocrinology workforce in this country is probably not set up to deal with the current deluge of new people referred for management of diabetes.”
At the same time, the specialists responsible for the treatment of diabetes complications are far less likely to see patients in the early stages when kidney, heart, and other complications are most manageable. For example, nephrologists have the most experience with SGLT2 inhibitors, yet are the least likely to see the patient early enough to be able to use the medications.
Dr. Afkarian is a nephrologist, but patients with diabetes are often referred to her when their glomerular filtration rate is below 30%. At that point, their kidney disease has progressed to the point they are no longer eligible for the SGLT2 inhibitors that can slow progression of DKD in its earlier stages.
“By the time people with diabetes finally get referred to me, all I can really do is escort them to dialysis, where 20% will die the first year of treatment and about 50% in the first five years,” Dr. Afkarian said. “If we could get to them before they lose so much kidney function, we would have the time to put them on a full complement of protective medications to slow progression of their DKD, keeping the patients off dialysis for years.”
This was one of the presentations I found very interesting at ADA 81st Scientific Sessions, and a big focus on early detection of DKD and interventions & the challenges faced, even though there are effective treatments now. I am not sure if the link to the presentation will work?
Professor Afkarian is involved in research in diabetic kidney disease, including in Paediatrics and also Urinary biomarkers to detect early CKD.
As we know, once there is macro albuminuria & decline in eGFR, the damage is already done and irreversible.
The natural history of kidney function decline is variable between patients and this second part of the Janssen study not only showed that patients with high risk scores showed the most benefit, but also that patients who did not have DKD at baseline on the CANVAS study & a high PromarkerD score, were correctly predicted to develop DKD later on in the 3 year study & benefit on treatment vs placebo.
So this is important in identifying patients with diabetes who may need to start on drugs to protect their kidneys earlier, not wait for permanent damage to occur (eGFR decline, albuminuria) when it becomes evident in these biomarkers.
SGLT2is are costly & that needs to be taken into account when putting patients on treatment & risk vs benefit of prescribing SGLT2I.
I’m just adding in one of Professor Afkarian’s earlier studies (abstract) on the natural history of UACR and DKD in teenagers & young adults, as you will see there are socioeconomic factors as well as biological, and there is more risk for DKD in patients who have Type2 DM as opposed to Type1.
DKD can be silent for many years in young people. We don’t really talk about kids & young adults here that much, but DKD is a problem in this population as well. I think anything you can do to safely prevent that happening is important. Last time I looked they were running SGLT2i trials in Paediatrics. It’s been a while, so there may be some updates.
, sorry just in regard to your comment on retrospective vs prospective, it is retrospective in the sense Janssen were aware of patient outcomes at year 3 & on the completed CANVAS study, but prospective in the sense analysing ~2000 samples from baseline at the commencement of the study to year 3. Bio banks are regularly used to validate tests.
If you look at cardiorenal studies, a lot coming out are post hoc analysis of CANVAS & CREDENCE, including use of the bio banks on these 2 large International clinical trials.
(20min delay)
